Journal of Autism and Childhood Schizophrenia, 1971, 1, 4, 453-459

Approaches: Retrospectand Prospect

LEO KANNER
Johns Hopkins University School of Medicine

A little more than 60 years ago, the foundation of the National Committee for Mental Hygiene evoked an unprecedented amount of enthusiasm which soon spread over the civilized portion of the globe. Its banner carried a lofty slogan: The prevention of insanity and delinquency. It had ~n exciting message: Give us people at the earliest age at which they have personal difficulties and we shall help them to stay out of mental hospitals and prisons. There is no earlier rime for this task than the years of sprouting and budding. As predicted in 1900 by Ellen Key, the noted gwedish sociologist, we found ourselves moving in what she said would be the "century of the child." For the first time in the history of mankind, the welfare of children was ushered in as an acknowledged and loudly acclaimed concern of scientists, social agencies, and governmental planners. In rapid succession, juvenile courts, special educational facilities, and child guidance clinics entered into the cultural texture as ingredients of communal responsibility. Child psychiatry came into its own as a widely ramified discipline devoted to the study, treatment, and preclusion of developmental and behavioral distress. Hardly ever had so much been achieved in so short a time in terms of man's efforts to improve the lot of his fellow men. Has all of this led even to an infinitesimal reduction of "insanity and delinquency"? I t has hot. Can we sit back with Pollyannish delight in contemplation of anticipated fulfillment? We can hot. Should we, therefore, despairingly, sardonically, or with shoulder-shrugging abandon turn our backs to the festive glee with which ail these innovations were brought into existence? We
shouM hot.

Dissatisfaction with things as they are is unquestionably an indispensable step toward progress without which there would be unimaginative stagnation. But it must be supplemented by curiosity about practical, attainable means of amelioration. This requires patient, self-critical inquiry and the setting of 453

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realistic goals without premature hosannas or excursions into pseudoomniscience. Goethe has tried ingeniously to deal with this issue in the famous confrontation between Faust and his famulus. Wagner represents the hosannas. Behold!, he declares, we have reached the acme of wisdom and we can forever bask in its resplendent glory. Faust cannot concur. Smarting from a conviction of ignorance, he succumbs to the ghostly phantom of omniscience. The Wagnerians in our midst, like their prototype, marvel at the advances ruade after ages of inertia, point with pride to the mushrooming proliferation of professionals, paraprofessionals, buildings, and monetary appropriations, and look for more and more of these accoutrements for the mental hygiene brigade. Local and national policies are set down, statistics are paraded, functions are delineated, and ail is well with the world. The Faustians, like their prototype, are restive in the face of the slowness and imperfections of human endeavor. Impatient with its piecemeal and often zigzagging pace, they grope for an all-encompassing breakthrough that would enable them to find an answer, the answer, to every question. Some of them, imbued with impeccable idealism and creative urge, have startled their contemporaries with revelations proclaimed with evangelical fervor and generally known as tightly systematized "approaches." This is a semantically fascinating term. You might think that it is the patient who approaches you with his problem and that you might take it up from there, depending on its nature, its varieties, implications, and complexities. No, say the approachers, it is we who have a ready-made, universal set of premises and techniques applicable to aU comers. Ail you have to dois learn the catechism and the rituals and you are safely on the way to salvation. Long ago, the moral and political philosophies started with exalted ideals for the benefit of humanity, with emphasis on eternal values which are the noblest aspirations of the species. Have they, in the course of several millennia, brought about the abolition of fratricide, tyranny, greed, and prejudice? They have not. This is because the basic goal has been split off into a variety of "approaches," each claiming the sole possession of the key to redemption. Ideals degenerated into ideologies, the golden rule into iron-fisted injunctions, religion into sectarianism. Inflexible sets of tenets and arrays of sine qua non procedures, each unique to a specific '~ have done very little for the furtherance of the goal on whose behalf it has been inaugurated. How does this apply to our own concern? A few examples may suffice: (1) The mental hygiene movement resulted in the creation of communal

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clinics which wisely recognized the benefits to be derived from the collaboration of ail those who had a hand in the guidance of troubled children and their families. There could bave been no more promising start than such a multidisciplinary arrangement. But what happened? The breadth of vision was promptly narrowed down to the much vaunted "team approach" of psychiatrist, psychologist, and social worker. The pediatricians, the educators, the juvenile courts, and all other groups were kept away from active participation and viewed superciliously as hopefully obedient recipients of the wisdom emanating from the established trinity. Were the portais of the clinics open to aU children with developmentai difficulties? The "approach" deemed it inconvenient to adroit those in the first few years of life, the intellectually handicapped, the organically damaged, the psychotically non responsive, and the offspring of "uncooperative" parents. Thus the services were limited to an elite of patients considered worthy of being "approached." (2) Since the dawn of civilization, many outstanding thinkers have said wise things about the soul, the mind, the morals, the destiny of man, as if "man" were a homogeneous category. In the past two centuries, anthropologists, physicians, teachers, and civic-spirited statesmen were increasingly impressed by the heterogeneity of the members of the species. The rights of the individual became the sacrosanct basis of the new democracies. It was in the field of education that the first concretely measurable criteria for heterogeneity were worked out, at least so far as application to scholastic aptitude was concerned. Standardized developmental assessments accentuated the need for special facilities attuned to the difference and adapted to the requirements of individuai children. When these were set up, the administrative "approachers" lost no time imposing rigid regulations centered around the IQ and would-be diagnostic labeling. Ail of us know of children who were kept out of classes for the retarded because they were emotionally disturbed and were refused admission to classes for the emotionally disturbed because they were retarded. We know of the heated battles, which have not yet fully subsided, between the advocates of continuous and of contiguous grouping-battles in which the theories of the two sets of "approachers" took precedence over practical planning for each child in accordance with his personal needs. (3) In no area of scientific search for the betterment of health has there been such a plethora of "approachers" as in contemporary psychiatry. It would be unfair to deny to any of them the acknowledgment of underlying earnestness and of a sincere desire to be of help. In fact, one often senses an overdose of

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goodwill and an impetuous straining to anticipate the ultimate triumph of etiologic omniscience and therapeutic omnipotence. Out of the multiplicity of factors which, in a vast variety of fusions, make up the complexity of human existence, each one of different leaders picked out a special set for the top hierarchical role as the basis of a supposedly all-valid "approach." The past few decades bave witnessed a fascinating procession of approaches of varying longevity, some with few and others with many adherents. Who still remembers the days when the apostles of the focal infection credo preached and practiced the removal of teeth, tonsils, appendices, gall bladders, and parts of the colon as a sure cure of schizophrenia (Cotton, 1921)? Who remembers the excitement created by the breathtaking discovery of the functions of the innersecretory glands, promptly seized upon by some as the unrivaled source of all human behavior and the promise of a therapeutic elixir? The "glands of destiny" (Cobb, 1927) and the "glands regulating personality" (Berman, 1921) were declared to hold the answer to all psychiatric curiosity. Who remembers the stir aroused by some of the new typologies, the reams of literature on anthropometric measurements claimed to be the infallible guides to characterologic predestination (Krasusky, 1927)? These "approaches" have had their day, not too long ago, in the lifetime of some of us. Most of them have their "kernel of truth"; some have ruade a few factual contributions which can be incorporated as fragmentary addenda to out body of knowledge. There are other approaches which still hold powerful sway. We are here concerned mainly with child psychiatry and more especially with the childhood psychoses. There are those who look on infantile sexuality alone, others on early mother-child relationship alone, others on faulty conditioning alone, still others on neuropathology or biochemistry alone as the open sesame to the gares of understanding and the passkey to therapeutic planning. What happens to a psychotic child and his family has often been "programmed" not so much in accord with the specific circumstances of each patient's illness as by the predictably uniform ritualism of the approacher's orientation.

Of course, this state of affairs could not go unnoticed. Adolf Meyer persistently spoke out against what he called "exclusive salvationism" of the splinter groups which, far from seeing themselves as such, paraded their credo as the infallible guardian of the truth, the whole truth, etc.

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At long last, in 1956, the situation reached a point when the Committee on Public Health of the New York Academy of Medicine convoked a conference headlined: Integrating the Approaches to Mental Disease; the proceedings were superbly edited by Kruse (1957). The broad aim was "to afford an opportunity to a group of experts who hold different views on the causalities, pathogenesis, and therapy of mental disease to corne together, to engage in cross-exposition, and to plan research in common." Prominent representatives of four "major categories" (1. organic, 2. experimental psychological, 3. psychodynamic, 4. psychosociat) took part in the discussions. "Each of these four groups," the editor said, "bas its distinctive methodology, vocabulary, and doctrine; to the others the methods of each are unfamiliar, the language strange, and the concepts esoteric." Throughout the debates, the terres "approaches," "positions," "viewpoints," "doctrines," and "schools of thought" were used synonymously. There was quite a bit of airing of intradoctrinal acceptance and unacceptance, common ground, communication and concept barriers. Ail this was intended to find a way out of "provincialism," "insular grouping," "segmentation," "fragmentation," "narrow vista," resulting in "restricted objective and approach." It cannot be said that those sessions bave changed the situation perceptibly. At the meeting itself, augmented in its second portion by men who had no doctrinaire commitments, politeness prevailed. The spokesmen for the four groups gave expression to their loyalty oaths, with elaborations, explanations, "defense mechanisms," and ever so subtle bows in the direction of the infidels. Tepid handshakes took the place of distant nodding acquaintances. The summary stated: "It was manifest that on a theoretical level there was much tolerance (sic!) on ail sides, but that differences developed rapidly in concrete situations. The transactions clearly reveal the basis of difficulties of mutual understanding and of planning a combined research project by the four approaches." One of the participants put it a little differently: "When we act in our role as scientists, we begin to see one another's problems; when we act the role of teachers of our pet theories, we tend to become more welded to our respective doctrines." After this memorable meeting, which constitutes a milestone in the history of psychiatry, the participants went home and, apparently unimpressed by what had happened, took up where they had left off. They had brought with them their neatly tied packages, had done their best to market their ware and, finding no takers in the other three groups, lugged them to their respective 1airs. Since then, however, there have been signs of a greater desire of an approximation between t e sundry sets of approachers. The heated battles for

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hegemony have simmered down to less passionate skirmishes. In fact, one occasionally catches followers of the various "schools" somnambulating in each other's camps.

These reminiscences and reflections appear to be particularly appropriate at the conclusion of the first (1971) volume of the Journal of Autism and Childhood Schizophrenia. This journal was inaugurated with the determination to serve as a vehicle for those studies and observations which would lead to a better understanding and to more effective means of prevention and treatment of the childhood psychoses. It set out to invite and encourage the reporting, coordination, and eventuat integration of data obtained from factual investigation of the problems which knock at our door, which approach us, instead of entering the arena equipped a priori with somebody's ready-made approaches for the readers' comparison or contrast, approval or disapproval. We bave managed to steer clear of the kind of frustrations which resulted from the talkfest arranged by the New York Academy of Medicine. We were, as the record shows, amply rewarded by receiving worthwhile contributions centered around the children, not around the claires, promises, sophisms, or pugilistically rolled-up sleeves of approachers. These efforts came from scientists representing, in accordance with the plans announced in the first issue of the journal (Brown, 1971), many areas of patient-centered, rather than approach-centered, curiosity. They were concerned with refinement of diagnostic criteria, epidemiology, phenomenology, neurology, biochemistry, ethological correlates, results of ameliorative endeavors (educational, psychotherapeutic, psychopharmacological, behavioristic) and follow-up studies. Abstracts of pertinent work published recently (1970-1971) in other-language periodicals (thus far-Russian, Japanese, and German) have been arranged to give the readers familiarity with important research not easily accessible to them in the original. Under ` circumstances, there is no room for doctrinal strife, for a contest of opinions. There is no call for the oratorical cleverness spent on proving or questioning the supremacy of a specific "approach." Nobody can argue about established, carefully documented facts presented so that, if there is any doubt, an experiment can be duplicated and an observation can be checked by anybody with a healthy Missourian "I-want-to-be-shown" attitude. The immediately following pages, which tabulate the contents of this journal's first volume, are an indication of the caliber of the contributions to corne. The editor wishes to

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thank the authors for the high standards attained by the journal from its incipiency. Their work paves the way for the accumulation of pertinent, scientifically unchaUenged knowledge. REFERENCES Berman, L. The glandy regulating personality. New York: Macmillan, 1921. Brown, B. S. A task force with a goal Journal of Autism and Childhood Schizophrenia, 1971, 1, 1-13. Cobb, I. B. The glands ofdestiny. London: Heinemann, 1927. Cotton, H. A. The defective, delinquent, and insane: The relation of focal infection to their causation, treatment and prevention. Princeton: University Press, 1921. Key, E. The eentury o f t h e chiM. (English rev.) New York: Putnam, 1909. Krasusky, W. S. Kretschmer's konstitutioneUe typen unter den kindern irn schulalter. Archiv f9 Kinderheilkunde, 1927, 82, 22-32. Kruse, H. D. (Ed.) lntegrating the approaches to mental disease. New York: Hoeber-Harper, 1957.